Services

Description

Catheter clinics started in Faversham in April 2016 (based at Newton Place), in Whitstable in May (based at Whitstable Medical Practice) and in Canterbury (based at Northgate) in July 2016.  This service is commencing at Bridge soon.  Whilst the clinics are practice based they support patients from across the Town localities.

Outcomes so far

Figures for 2016/17 showed a 21% reduction in A&E attendances for catheter related problems.

Referral

Patients can self-refer to access the service: Patient self-present at the surgery where the service is offered.  When the patient is discharged from urology the local hospital notifies the GP surgery where the patient is registered and the patient is informed of support services available within the community.

Description

A CHOC is a Community Hub Operating Centre. They are where professionals including GPs, geriatricians, social care, community nurses, mental health and social prescribers (with others joining where appropriate) work together to look at patients who are at risk of being admitted to hospital. They allow professionals to work together and share information.   There are 5 CHOC MDTs; Ash / Sandwich, Canterbury North, Canterbury South, Faversham Medical Practice / Newton Place and Whitstable.

Outcomes so far

669 patients had been discussed at the end of March 2017.

Referral

Referral is via the LRU/the Health and Social care coordinator/at the MDT.

Description

Two Geriatricians are employed by Kent Community Health Foundation Trust who are MDT facing and attend CHOCs.  One more Geriatrician is being recruited. Geriatricians support medical decision making to keep people well in their own homes.

Referral

A Geriatrician referral can be made via the LRU at the CHOC/MDT.  Monday to Friday 12 noon to 2pm there is a Clinician to Clinician advice and guidance service to discuss frail patients at risk of acute hospital admission in the next week.  The phone number for this service is 0300 1234498.

View the flyer here

The service

Encompass is working with Age UK to provide drop-in dementia clinics for those suffering with dementia.  The service also provides support for families and carers.

Outcomes so far

January 2017 to March 2017: contact made with 191 carers of which 104 requested further support.

Referral route

Referral from the acute or through the CHOC/MDT

The service

12 Practitioners have signed learning agreements for GPs with special interest (GPwSI) training.  Encompass has supported this training with matched funding for backfill and course costs. The seven speciality areas include: Dementia,  Dermatology, ENT, Urology, Ophthalmology, Respiratory and Cardiology.

Outcomes so far

The majority of the practitioners will commence training in September 2017. A number of practices offer a GPwSI service and this can be access through the practice and the CCG Referral Support Tool Click here to view.

Canterbury and Coastal CCG have a referral support tool to show which services are provided by whom. To view the tool please visit their website.

The service

Health and Social Care Coordinators support the CHOC MDTs.  They are a key link between the patient and the staff supporting them.

Outcomes so far

669 patients had been discussed at the end of March 2017.

Referral

Referral is via the Local Referral Unit  at the CHOC/MDT.

The service

Following the pilot at Northgate Medical Practice, Health Trainers will be rolled out to Canterbury North, Ash & Sandwich and Faversham by September 2017.  Health Trainers work with clients to develop a personal health plan that suits the individual and set primary goals i.e. weight reduction, stop smoking, physical activity and general health.

Outcomes so far

149 clients seen in 2016/17 with 81% achieving all their goals.

Referral

Practices can refer directly to the Health trainer aligned to their practice.

The service

Encompass is working with Invicta Health to support self management/admission avoidance for individuals with long term mental health (bi-polar, schizophrenia).

Outcomes so far

The groups have helped individuals to be less isolated by meeting others with a similar diagnosis and have helped them to understand their condition and learn about relapse prevention to enable them to stay well and out of hospital.

Referral

GPs can write a letter or complete a referral form held on the GP system and email to: invictahealth.mentalhealthreferrals@nhs.net

Service
Support the MDT around complex patients involving facilitating discharge, preventing admission and visiting the patient in their own home to optimise their medication.

Outcomes so far
Attend CHOCs and support patients in the community. In post from April 2017.

Referral

Via the LRU/the Health and Social care coordinator/at the MDT.

The service

Encompass has been working with Red Zebra to develop and build a database of voluntary and community services that service users and practitioners can access.

Outcomes so far

164 patients have been referred up to April 2017.  The highest reason continues to be social isolation followed by health condition and career needs.

Referral

The service can be accessed by the social prescribing team through the Connect Well Kent website and through the CHOC/ MDT.

The service

A smart phone app (linked to health help now) launched in December 2016 designed to help people decide which urgent care centre to head to for faster treatment for minor injuries.

Outcomes so far

95,000 uses and 12,500 downloads up to June 2017.  11% shift of minors from A&E.  A 5 %  decrease in MIU attendees.The WaitLess app is free to download for apple hereclick here and for android (click here)